Complete Text (Part 1)

lPresente& to ttc of tbc flliebical Society of tbe (Eountie of Ikinge ot ^ CI J .5.4.9.149 Digitized by tlie Internet Archive in 2014 https://archive.org/details/b20424826 A MANUAL Physical Diagnosis FRANCIS DELAFIELD, M.D., CHARLES F. STILLMAN, M.D. NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES ST. 1878. WELLGOP < PREFACE. " I ^HIS Manual is intended for the use of those who have to teach and to learn the art of physical diagnosis. It is made as concise as possible, and bound interleaved that it may be taken into the wards, and used as a note-book as well as a guide. It is impossible to prepare such a Manual without making use of the works of Walshe, Flint, and Sibson, and I have done so freely. The drawings have been prepared by Dr. Stillman, and are original. The idea of superimposed plates is, of course, an old one, but is of much practical value. The object of the entire work is to furnish a sort of skeleton, to which each one may add the facts furnished by his own observation. FRANCIS DELAFIELD, 12 West Thirty-second Street. Physical Diagnosis. METHODS OF EXAMINATION. In the examination of the thorax and abdomen we make use of Inspec- tion, Palpation, ^.Mensuration, Succussion, Percussion, and Auscultation. PERCUSSION. In practising percussion we may simply use the fingers, or we may employ any of the different varieties of hammers and pleximeters. If you use your fingers, you apply the palmar surface of the left index or middle finger to the patient's body, and you strike this with the tips of the fingers of the other hand. If possible, the finger used as a pleximeter should be applied directly to the skin. It is important that this finger should be pressed closely to the patient's body, so as to form, as nearly as possible, a continuous substance with it. In striking this finger you should make a blow, not a push. Imitate the hammers of a piano-forte. It is more important to elicit a correct sound than a loud one. The sounds are made more distinct by placing the patient with his back against a door, which acts as a sounding-board. The Sounds produced by Percussion. There are four characteristics to be noticed in every sound which we elicit by percussion. These are : Quality, Pitch, Intensity, Duration. The Quality of a sound is the individual peculiarity which distinguishes it 6 PHYSICAL DIAGNOSIS PERCUSSION. from other sounds, apart from its pitch, duration, and intensit}^ Thus every musical instrument produces sounds of a quality peculiar to that special instrument. The Pitch of a sound means the same as the term does in music. We obtain percussion sounds of many grades of high and low pitch. The Intensity is simply the loudness of the sound. The Duration is the length of the sound. Percussion of the Normal Thorax and Abdomen. Over the normal chest and abdomen we obtain by percussion four different kinds of resonance : Pulmonary Resonance, Dulness, Flatness, and Tympanitic Resonance. 1. Pulmonary^ Resonance is the resonance obtained over healthy lungs. Its quality is pulmonary, its pitch is low, its duration is consider- able, its intensity varies in different chests. 2. Dulness is an altered pulmonary resonance. It is heard where the chest-wall is thickened by bone and muscle, or where the liver and heart are in contact with the lung. Its quality is imperfectly pulmonary, its pitch is high, its duration is short, its intensity is not great. There are many degrees of dulness. 3. Flatness is not an absence of sound, but a sound produced by per- cussion of certain parts of the body. It is heard over the solid viscera, the liver, spleen, and kidneys, and over the thick muscles of the back. Its quality is flat, its pitch is high, its duration is short, its intensity is not great. Flatness differs from dulness chiefly in its quality. It is not a mere degree of dulness, but a sound of different quality. 4. Tympanitic Resonance is a sound of a peculiar quality, called tym- panitic. It is heard over the stomach and intestines. Its quality is tym- panitic, its pitch is high or low, its duration is considerable, its intensity is marked. The characteristic feature of tympanitic resonance is its quality. This quality is something positive. A sound may have any kind of pitch PHYSICAL DIAGNOSIS PERCUSSION. 7 or quality ; but if it does not have this one peculiar quality, it is not tym- panitic. Regions of the Chest and Abdomen. As a matter of convenience, the surface of the chest and abdomen is divided into a number of regions, which are designated by arbitrary names. Over the thorax there are so many natural bony landmarks that these regions are not of so much importance ; over the abdomen they are very useful. It is absolutely necessary to know the positions of the thoracic and abdominal viscera. They may be seen in the plates. The followinof enumeration of the viscera situated in the different regions of the abdomen is copied from Ouain's "Anatomy": Epigastric Region, -phe right part of the stomach, the pancreas, part of the liver, and the aorta. Right lobe of the liver, the gall-bladder, part of the duodenum, the hepatic flexure of the colon, part of the right kidney, with its supra-renal capsule. The large end of the stomach, the spleen, the narrow extremity of the pancreas, the splenic flexure of the colon, the upper part of the left kidney, with its supra-renal cap- sule, and sometimes part of the left lobe of the liver. Part of the omentum and mesentery, the transverse colon, the lower part of the duodenum, some parts of the jeju- num and ileum, the abdominal aorta. The ascending colon, lower half of the kidney, and part of the duodenum and jejunum. The descending colon and lower part of the left kidney, with part of the jejunum. The ileum, the bladder, if distended, the gravid uterus. The caecum, the appendix vermiformis, the lower end of the ileum. The sigmoid flexure of the colon. Hypochondriac, right Hypochondriac, left. Umbilical. Lumbar, right. Lumbar, left. Hypogastric. Iliac, right. Iliac, left.' 8 PHYSICAL DIAGNOSIS — TOPOGRAPHY. The Examination of the Normal Chest and Abdomen by Percussion. Supra-clavicular Qti both sidcs of the bodv the small res^ions iust above Regions. _ . the clavicles, into which project the apices of the lungs, give dulness on percussion. The sound becomes more pul- monary if the lungs are fully inflated. In percussing these , regions hold the fingers so as not to get the resonance from the clavicles or sternum. Infra-clavicular Re- Qn the left side, in front, from the lower edge of the gions. clavicle to the upper edge of the third rib, there is pul- monary resonance. On the right side, in front, from the lower edge of the clavicle to the top of the fourth or fifth rib, there is pulmonary resonance, usually of higher pitch than that on the left. Precordial Region. Qver an area corresponding to the size of the heart, as seen in the plate, there is dulness on percussion ; where the heart is uncovered by lung this dulness is more marked, or there may be flatness. Where the sternum covers the heart, the bone changes the quality of the percussion note. Hepatic Region. Qn the right side, in front, there is dulness on percus- sion, from the upper edge of the fourth or fifth rib to the free border of the ribs. Over the sixth and seventh ribs, in the same region, there is usually flatness. Sternum. Over the entire length of the sternum the resonance is pulmonary in character, but of increased intensity and of altered quality. The pulmonary quality is more apparent if gentle percussion is used. From the level of the third rib to that of the eighth cartilage the resonance over the sternum is rendered dull by the heart. Left ^Hypogastric Qver this region there is often tympanitic resonance, especially if the stojnach is dilated. / PHYSICAL DIAGNOSIS — PERCUSSION IN DISEASE. 9 Anterior Abdonii- There IS usuallv tympanitic resonance over the entire nal Region. ^ j ^ anterior abdominal wall, except in the upper part of the epigastrium, where the left lobe of the liver gives dulness. Supra-scapular Over both supra-scapular regions there is dulness on Regions. ^ ^ " percussion. The more muscular or fat the individual, the greater the dulness. The pulmonary quality is rendered more evident by forcible percussion. Scapular Regions. Qver both scapulae the percussion sound is also dull. The thinner the patient, the less evident the dulness. The pulmonary quality is made more evident by forcible per- cussion. Infra-scapular From the angfles of the scapulae downwards, on both Regions. sides, for a distance of about five inches, in adults, there is pulmonary resonance on percussion. Below this, over the rest of the back, the percussion note is flat. The line of flatness is usually about an inch higher on the right side than on the left. Axillary Regions. ^ of the axilla, ou the right side, there is pul- monary resonance from the axilla down to the fifth rib ; at that level there is dulness. The dulness extends down to the seventh rib, at which level there is flatness. The flat- ness continues down to the free edge of the ribs. On the left side dulness begins at the level of the sixth rib ; at the level of the seventh rib, and below it, there may be either dulness, flatness, or tympanitic resonance. Inter-scapular Over the regious between the inner edg-e of each scap- Region. ^ i ula and the vertebral column there is pulmonary resonance on percussion. Percussion in Disease. The varieties of percussion sound heard in disease are : Pulmonary Resonance, Dulness, Flatness, Tympanitic Resonance, Amphoric Reso- nance, and Cracked-pot Sound. lO PHYSICAL DIAGNOSIS— PERCUSSION IN DISEASE. 1. Pulmonary Resonance. — The pitch and the intensity of pulmo- nary resonance may be changed. The pitch is higher and the inten- sity greater over one lung when the other lung, from any cause, does not respire; over lung floating on the top of fluid; over the lungs in cases of empjiysema ; over the ribs when they are unnaturally dry from old age or disease. 2. Dulness may be heard over those parts of the chest where nor- mally there is pulmonary resonance, and it may be increased over those parts of the chest where it is heard in health. Dulness may be produced or increased — (i.) By any cause which thickens the chest- wall : pleuritic adhe- sions, tumors. (2.) By accumulations of fluid in the pleural cavities. (3.) By any solidification of the lungs : oedema, hemorrhages, pneumonia, phthisis. (4.) By emphysema of the lungs in some cases. (5.) By hypertrophy of the heart, liver, and spleen ; by aneu- risms, by abscesses, and by tumors. 3. Flatness is produced by — (i.) Very thick pleuritic adhesions. (2.) By large accumulations of fluid in the pleural cavities. (3.) By complete consolidation of the lung, especially if the lung is closely adherent to the chest-wall. (4.) By hypertrophy of the viscera, by aneurisms, by abscesses, and by tumors. 4. Tympanitic Resonance is heard over air in the pleural cavities, over large cavities, over solidi^ed lung, over lung compressed by fluid, and in some cases of emphysema. 5. Amphoric Resonance is a variety of tympanitic resonance, with a peculiar musical quality. It is heard over large cavities, over air in the pleural cavities, over^olidified lung. 6. The Cracked-pot Sound is also a variety of tympanitic reso- nance, with a peculiar metallic quality. PHYSICAL DIAGNOSIS AUSCULTATION. II In order to obtain this sound, the patient should keep his mouth open while percussion is made. The sound is heard over cavities, over solidified lung, over lung compressed by fluid, and over the infra- clavicular regions of some healthy children. Auscultation of the Breathing in Health. In listening to the breathing we must distinguish the inspiration and the expiration. Of each of these — the inspiration and the expira- tion— we must notice the quality, the pitch, the intensity, and the dura- tion. Over the healthy chest we can hear three kinds of breathing : Pulmonary Breathing, Bronchial Breathing, and Broncho -vesicular Breathing. 1. Pitliuonary BreathiugX—The. inspiration is of pulmonary quality, low pitch, considerable duration, and variable intensity. The expira- tion is of pulmonary quality, of lower pitch, of short duration, of vari- able intensity. It is abseir^ in many healthy chests. In the right infra-clavicular region both inspiration and expiration are often of higher pitch, and the expiration is longer than over the rest of the chest. In children the breathing is usually more intense. In old age the expiration is often longer. There is much difference in the intensity of the breathing in the chests of different healthy adults. 2. Bronchial Breatkijtg.^Th^ inspiration is of tubular quality, of higher pitch, of marked intensity, and of considerable duration. The expiration is of tubular quality, of higher pitch, of greater intensity, and of longgr . duration than inspiration. This kind of breathing is heard over the larynx, the trachea, and the upper part of the sternum. 3. Broncho-vesicitlar Breathing. — This variety of breathing is inter- mediate in its character between pulmonary and bronchial breathing. It may partake of the character of each. The quality approaches to that of bronchial or of pulmonary breathing. The pitch is higher than that of pulmonary breathing ; not as high as that of bronchial breath- ing. The expiration is longer and higher pitched than in pulmonary 12 PHYSICAL DIAGNOSIS AUSCULTATION. breathing. This kind of breathing can often be heard in the inter- scapular region. The Breathing in Disease. 1. Exaggerated or puerile breathing is heard over the lungs of children, over a lung or a part of a lung which is doing extra work, and over the lungs in some cases of vesicular emphysema. 2. Diminished breathing is heard over lungs into which less air than usual is inspired. Very frequently this is the case in phthisis and in emphysema. To judge of diminished breathing it is usually necessary to compare the breathing over the suspected portion of the lung with the breathing in other parts of the lungs. 3. Suppressed breathing is observed when very little or no air en- ters the lungs. ' This may be the case in pleurisy with effusions, intra- thoracic tumors, obstructed bronchi, pneumonia, and phthisis. 4. Bronchial Breathing. — Its quality is tubular or bronchial, its pitch is high, the expiration is longer and higher pitched than the inspira- tion. It is heard over consolidated and compressed lungs, and over cavities. 5. Broncho-vesicular breathing, intermediate in its characters between- bronchial .and pulmonary breathing, is heard over lesser degrees of con- solidation and compression of the lung. 6. Cavernous Breathing. — Its quality is cavernous, its pitch low, the expiration is longer and lower pitched than the inspiration. The name is used to designate the character of the breathing, not the way in which it is produced. It is heard over cavities, over consolidated lung, and over compressed lung. 7. Amphoric breathing resembles cavernous breathing, except in its quality, which is of a peculiar musical character. It is heard over large cavities, and over the chest in pneumothorax. 8. Sibilant Breathing. — Its quality is whistling, its pitch high, its expiration prolonged. PHYSICAL DIAGNOSIS AUSCULTATION. 13 Sonorous Breathing. — Its quality is sonorous, its pitch low, its ex- piration prolonged. Both sibilant and sonorous breathing are heard in some cases of acute and chronic bronchitis, in emphysema, and in asthma. They are supposed to be caused by irregular contraction of the walls of the bronchi. RAles. The word rale is used to designate certain abnormal sounds which accompany the breathing. These sounds are not heard over healthy lungs. We distinguish Crepitant, Subcrepitant, Coarse, and Gurgling Rales. 1. The Crepitant Rale is a very fine, dry^ crackling sound, heard only at the end of inspiration, iiot,. in expiration. The sound is devel- oped abruptly in puffs immediately beneath the ear. It is often neces- sary to make the patient cough, in order to develop this rale. It is heard in pneumonia, in phthisis, and in dry pleurisy. 2. The Subcrepitant Rale is a fine, moist, bubbling sound, heard both in inspiration and in expiration. It is heard with bronchitis, pleurisy, pneumonia, phthisis, and oedema of the lungs. 3. Coarse, Mucous, or Bronchial Rales are like the subcrepitant rale, but louder and coarser. They are heard with acute and chronic bronchitis, pneumonia, and phthisis. 4. Gurgling Rales are very coarse rales, with a peculiar gurgling character. They are usually heard over small cavities, but sometimes in the bronchi of compressed lung. If a patient has at the same time sibilant or sonorous breathing and subcrepitant or coarse rales, he may be said to have sibilant or sonorous rales. Auscultation of the Voice. If we place our ear on a person's chest and cause him to speak, we hear at the same time the sound of the patient's ' voice as it is 14 PHYSICAL DIAGNOSIS THE VOICE. transmitted through the air and through the wall of his chest. It is necessary for us to abstract our attention entirely from the first of these sounds, and only listen to that which is transmitted through the chest. In doing this we are much aided by the use of Cammann's stethoscope. The quality of the sound, however, is not as well ap- preciated by the stethoscope as by the ear alone. In listening to the voice we must notice the intensity, the pitch, the quality, the distinctness, and the thrill. Changes in the quality of the voice can sometimes be appreciated when the patient whispers, which are not heard when he speaks in an ordinary tone of voice. 1. Laryngeal Voice. — -The quality is laryngeal, the